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Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect 7 of 14 patients.

Findings:
During the facility tour December 9, 2019 between the hours of 10:30 am and 1:00 PM and December 10, 2019 between the hours of 9:00 am to 3:40 PM, it was observed the main fire alarm panel had indicated a silenced supervisory trouble and a silenced battery trouble.

The fire alarm system should meet the requirements of NFPA 72: 10.3.2 which states System Components shall be installed, tested, and maintained in accordance with the manufacturer's published instructions and this Code.

NFPA 72: 10.4.2.1 State or local licensure regulations shall be followed to determine qualified personnel. Depending on state or local licensure regulations, qualified personnel shall include, but not be limited to, one or more of the following: (1) Personnel who are registered, licensed, or certified by a state or local authority.

LRS 40:1646 (A) (B) (C) The Fire Marshal is authorized to cause the inspection and testing of all life safety systems and equipment in the state, whether in public or private buildings, during installation or immediately after installation to determine compliance with applicable standards. The owner of any building containing a life safety system and equipment shall cause at a minimum an annual inspection to be made of the life safety system and equipment in that building to assure compliance with applicable safety standards and to determine whether structural changes in the building or in the contents of the building mandate alteration of a system. Life safety systems and equipment includes but is not limited to fire sprinkler, fire alarm, fire suppression, special locking systems and equipment, and portable fire extinguishers.

Interview with the Administrative Assistant and the Chief Executive Officer revealed the facility was not aware that the fire alarm system had was indicating a trouble alarm for both the supervisory and battery.

Based on visual observation, the facility failed to provide electrical wiring and equipment in accordance with NFPA 70. Improper wiring creates a high risk of injury and/or death. The deficiency has the potential to affect 7 of 14 patients.

Findings:
During the facility tour and record review on December 9, 1029 between the hours of 10:30 am to 1:00 PM to December 10, 2019 between the hours of 9:00 am to 3:40 PM , it was observed a receptacle cover was missing in patient room number five and light switch cover missing in patient room 10A/10B as well as a Phillips six outlet tap located in patient room number six. The patient room number 2 receptacle outlet nearest the interior access door was not energized. The electrical receptacle outlet nearest the patient interior access door to patient room number 9 had been painted and was not secured properly to the wall. The Administrative Assistant was lacking a documented electrical certificate from a licensed electrician and an annually documented polarity, ground and retention test.

NFPA 101: 9.1.2. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

LAC 55:v:105 (A) In order to assure that the electrical wiring in any structure or movable will not cause a fire or explosion, the electrical wiring in any structure, watercraft or movable shall be inspected and, if necessary, repaired by a licensed electrical contractor in accordance with the National Electrical Code.
(B) In order to assure that any structure, watercraft or movable is safe from hazards caused by gas piping, all gas piping shall be inspected and, if necessary, repaired by a licensed plumber or mechanical contractor in accordance with the applicable National Fuel Gas Code of the National Fire Protection Association and the provisions of the Louisiana Revised Statutes.
(C) The inspections require by this regulation for electrical wiring and gas piping shall be made at the time of the initial installation and thereafter as required based upon a visual inspection by the fire marshal or his designated representative.

Interview with the Administrative Assistant, revealed the facility was aware a documented electrical certificate from a Louisiana state licensed electrician identifying the electrical wiring within the Hospital Facility appears to be in accordance with National Electrical Code/ NFPA 70 and furnished to the Life Safety Code Surveyor. The Administrative Assistant is in the process of hiring a Louisiana state licensed electrician. The Administrative Assistant was not aware a documented polarity, ground and retention test for all patient care rooms must be completed annually and furnished to a Life Safety Code Surveyor.